March 25, 2022

Anatomy of a Medical Record

Just like a roadmap or if you use a map direction app such as MapQuest or Waze, one needs a start and end point. The same principle or concept applies to the medical record. There is a definite starting and ending point for a medical record, whether inpatient, observation, office visit, or ED to name just a few settings. Let’s focus upon hospitalization…More than half of patients are admitted to the hospital from the ED so that for all intents and purposes is the starting point.
February 28, 2023

PRESS RELEASE

Most Clinical Documentation Integrity (CDI) programs are mislabeled and misidentified in the present format. Integrity is defined as the quality or state of being complete or undivided per Merriam-Webster. A few years back the association representing the Clinical Documentation Improvement Specialist’s community elected to replace the “Improvement” part of the name to “Integrity”, now referred to as Clinical Documentation Integrity Specialists.
March 25, 2022

CDI – A New Day

The majority of CDI programs rely on the query process as the fundamental hallmark of documentation improvement. This query process has steadfastly maintained its stature in the industry as the bell weather for CDI for over twelve years. Recent conversation with several CDI professionals has increased my confidence that early adopters to change in present CDI query processes are finally seeing the light, recognizing the need for CDI redesign and reposition
March 26, 2022

Documentation Improvement-A Strategy for Denials Avoidance

One major way organizations can reduce claims denials is to truly focus upon root cause analysis, take a hard look at avoidable unnecessary denials, develop a management action plan and engage in process improvement that holds stakeholders accountable.Case in point, bring into the fold CDI specialists and hospitalists who in some respects to medical necessity & clinical validation denials as well as DRG downcodes.
March 25, 2022

Hospital Readmissions – Driving Reduction Through Enhanced Patient Care Communication

Palmetto GBA just this week posted on its website an article titled Hospital Readmission Without Septicema discussing the CMS Hospital Readmission Reduction Program. pointing out the cost of unplanned readmissions is $15 to $20 billion annually. Interesting enough the following statements in the article run contrary to findings of a study published in January’s Health Affairs
March 25, 2022

The Ideal State of CDI

The Ideal State of CDI- Collaborating Synergistically With All Other Ancillary Healthcare Roles to Achieve Real Meaningful Improvement in the Communication of Patient Care. Let’s Not Forget the Patient in any CDI Initiative. Reimbursement is a byproduct measure of documentation improvement that is sustainable over time. Rather than CDI specialists focus primarily upon capture of diagnoses, i.e., CC/MCC, principal diagnosis shift, HAC and PSI clarification
March 25, 2022

CDI- Moving Into The 21st Century

Clinical documentation integrity programs have evolved over time with its expansion of duties and responsibilities beyond CC/MCC diagnosis capture. The profession has expanded its reach into quality measures such as Hospital Acquired Conditions, Patient Safety Indicators, Core Measures, and other documentation driven reportable measures of care. Fundamental to operational performance of any clinical documentation integrity program is enhancing the physician’s
March 25, 2022

Is Your CDI Program Really Performing at the Top of Its Game

As outlined in the 2019 Medicare Fee-For-Service Supplemental Improper Payment Data Report, the overall Medicare Improper Payment Rate was pegged at 7.3% translating into $28.91 billion paid to providers improperly. This is a marked improvement from 2018 when the improper payment rate was 8.1% which represented $31.62 billion. The bulk of those improper payments paid by Medicare in 2019, similar to 2018, were attributable to two related
March 25, 2022

Take Stock in Your CDI Program-Check Under the Hood

Complacency is the main contributing factor that leads to suboptimal performance and achievement of sustainable operational processes and outcomes for any business. Clinical documentation improvement programs have discounted the necessity to evolve with the times, overlooking critical opportunities to contribute to the overall welfare of the healthcare delivery model. A strong CDI program for the right reasons with an underlying commitment to achieving
March 25, 2022

Complacency Can Starve Your Career GrowthResuscitation of CDI

I recently talked with a colleague on the phone who has been out of work for over a year now, this despite the fact the economy is performing well on all major indices. Now, granted my colleague has her age going against her as a strong headwind, she has been actively searching for a book-keeping related position day in and day out with little results. My colleague has been a bookkeeper for over twenty-five years with a very stable work history, having been at her last